Health reform: The human resource challenges for Central Asian Commonwealth of Independent States (CIS) countries
Article Outline
- Summary
- Introduction
- The breakdown of the Soviet health system
- Health reform
- Country profiles (see Figure 1 for a summary of data for each of the three countries cited below.)
- Health system reform and human resource issues
- Conclusion
- References
- Copyright
Summary
This paper examines the key human resource issues for health amongst mid-level workers in Central Asia CIS countries. It focuses on Azerbaijan, Tajikistan and Uzbekistan highlighting the human resource issues that are evident within these countries and illustrating how they differ from those described in the sub-Saharan developing countries.
The key human resource issue highlighted by the World Health Organization Report [WHO. (2006). World Health Report: Working together for health. Geneva: WHO] was the scarcity of health workers. Four million health care workers were identified as essential if the health services of the world are able to meet current health needs. The primary area of need highlighted was in Africa. Africa bears the greatest burden of disease but has the lowest number of health care workers. In the CIS countries in Central Asia different human resource issues have emerged. The Soviet health care system was comprehensive but labour intensive it had a primarily acute and a specialist disease focused approach with little investment in primary and community health care. It was unsustainable and the legacy that it left the new Central Asian emerging nations was of a large workforce with poor levels of competence and outdated approaches to providing care along with a crumbling infrastructure. In response to this situation health reform has been introduced which focuses on a family model of primary health care with family doctors supported by Family Health Nurses. This approach is beginning to make a difference to the morbidity and mortality of the populations but still has a long way to go before its full benefits are realised.
Keywords: Human resources, Health reform, Soviet health system, CIS countries, Family, Nursing
Introduction
The global human resource crisis has been well described in the World Health Report Working Together for Health (2006) and because of the high profile given it by the Global Health Work Force Alliance (GHWA) and WHO, it is now recognised and acknowledged as a key issue for health improvement by policy makers worldwide. The human resource requirements within any health care system are critical for its effective working. In order to provide these requirements, a full understanding of the community that is being served and its changing health needs is necessary, as well as clearly defined roles and responsibilities for the health care staff of all cadres.
The human resource issue that has been highlighted in the WHO report is the shortage of both capacity and capability amongst health care workers, exacerbated by the migration of the workforce to developed countries where they receive improved pay and conditions of service. Education and training to address the capability and capacity issues are identified as key factors in the scaling up of human resources for health, and this is summarised by Crisp, Gawanas, and Sharp (2008).
Attempts have been made by the Northern countries to curb migration with policies that increase the number of home prepared health staff and those that make immigration more difficult to achieve. Migration however only accounts for a small proportion of health workers from developing countries, albeit significant given the shortages, and there is a much larger underlying problem which is the result of years of neglect and failure to fund education and training for mid-level workers and to ensure investment in the health system, particularly the primary health care system. Much of the focus has been on Africa because Africa suffers the greatest need in term of workforce requirements. Overall the World Health Report highlighted that there is a global shortage of approximately 4.2 million health care workers and Africa, which carries 25% of the world's disease burden, has 3% of the world's health workers. It emphasises the critical need to scale up the workforce rapidly. Because of the prominence given to Africa's needs there is a danger that poor countries in other parts of the world are having the African solution applied to them when there are distinct differences in both the profile and the solutions needed. Rechel, Shapo, and McKee (2005) question the appropriateness of the Millennium Development Goals for Eastern Europe and Central Asia and points out that in spite of the recent deterioration of health information systems, since the fall of the Soviet Union there remains the skeleton of infrastructure to support the development of enhanced and developed health service provision. Infrastructure which in many cases does not exist in Africa. The same can be said of the human resource issues, which although they are similar to those in Africa they are not the same. The main human resource development strategy that is being applied in the sub-Saharan countries is the development of Community Health Workers, alongside the scaling up of capacity amongst other mid-level health workers. The emphasis is on increasing the numbers of health care workers to offset the huge deficit that has been identified. The situation in the Central Asian countries of the previous Soviet Union is quite different as the number of health care workers is not an issue; in many cases these countries have higher ratios of health professionals to population than the European average of 3.6. The key issues in these countries are low levels of competence and ineffective health service provision.
This paper will focus on three CIS countries; Azerbaijan, Tajikistan and Uzbekistan, to illustrate how both the human resource needs and the solutions are different in these countries and how they illustrate the situation in other similar CIS states.
The breakdown of the Soviet health system
The Soviet system of health care was both comprehensive and sophisticated, providing a network of health facilities across all the countries of the Soviet Union. This included health houses, rural clinics and polyclinics, Feldscher posts, district hospitals and regional hospitals as well as specialist facilities for maternity and women's health. The system was supported by comprehensive and laborious administrative reporting processes and funding was allocated according to defined treatment regimes and determined bed occupancy rates (Gotsadze, Zoidze, & Vasadze, 2004). Using prescribed regimes for treatment led to high levels of bed occupancy, with the result that many people were admitted to hospital that did not need to be there. There was little in the way of preventative medicine and public health and mental health services and services for the disabled were outdated and poorly funded. During the latter period of Soviet Control, health services were increasingly underfunded with little capital funding allocated leading to poor resources and infrastructure and lack of essential equipment (http://www.russians). Staff also received low levels of pay, often late, and this resulted in poor motivation and low morale. This situation gave rise to many unofficial systems of payment emerging with informal payments being made to all cadre of health care staff (Belli, Gotsadze, & Shahriari, 2004).
Following the collapse of the Soviet Union, newly emerging Governments have been forced to rethink the infrastructure of their health services. Consequently, major health service reforms are now underway. Sheaff (2005) pointed out that the economic collapse and social dislocation that resulted from the breakdown of the Soviet Union made it harder to manage the health services but at the same time these circumstances stimulated the reform process. These reforms in the health service have been comprehensive. Health care workers have been traditionally low paid with few resources and the opportunity to change their circumstances through reform was attractive to many. The reforms sought to address not only the collapsed infrastructure that resulted from the withdrawal of central financial support, but also encourage a Primary Health Care focus. The Soviet system had previously favoured the acute provision of services and this had led to poor levels of trust by the population in the primary health services. It was now necessary to reverse this lack of trust and provide new services that enhanced both the skills and the knowledge of doctors and nurses towards generalist provision, and with improved facilities and infrastructure to provide effective primary health care services.
The training and education of the Soviet health workforce was also highly specialised with clear boundaries of practice beyond which it was often both difficult and illegal to stray. This mitigated against a holistic approach to care, with different specialist doctors responsible for different parts of the body supported by specialist nurses. The most generalist of all medical practitioners was the paediatrician, who had responsibility for children and thus had an overview of all the main health issues affecting an individual, albeit a child. Education for nurses provided a very basic training in nursing skills and was targeted towards preparing assistants for doctors and in many cases commenced at an early age, with students admitted to medical schools aged 15 and 16 years old. The educational programmes consisted of a large general education content and the nursing or medical component often only extended over 18 months with little real practice or supervision.
Health reform
The shift from acute care to primary health care has required a major change in the way the health system works in many of the CIS countries. The Soviet model did not develop integrated primary health services and patients received health care through a wide range of access points. Current health reforms aim to improve access, especially for those in remote areas, it also aims to improve the quality and sustainability of the services. The upgrade of skills and knowledge for health staff through training and education is a major commitment. This training will also include management skills which have largely been ignored and not seen as relevant for medical and nursing staff. Increasing the understanding of community participation and engagement in health improvement programmes by local populations is also seen as critical for a real shift towards family focused care and health reform. Finally, improvements in infrastructure and provision of essential supplies and basic equipment are necessary.
Under the Soviet system, nursing was a low-status and low-skill profession, and many tasks that would have been done by nurses in Western countries were being carried out by physicians (McKee, Figueras, & Chenet, 1998). With the health reform process it is necessary to improve the skills and expertise of both doctors and nurses and in doing so raise their level of competence and the trust that the community will put in them. Family Medicine programmes of education have been introduced and many doctors have undergone retraining programmes to prepare them as Family Physicians or General Practitioners. Programmes for retraining nurses have been introduced more slowly but there have been developments in some CIS countries to raise the level of the pre-qualifying education to European standards as set out in the WHO (Wallace, 2001) standards for practice for general nurses, and to provide postgraduate training for Family Health Nurses, midwives and community nurses. Job descriptions have also been rewritten giving nurses greater autonomy and extended roles within the primary health care system.
Three countries will now be considered in the light of the developments described above and the human resource issues that have been raised by their engagement with this process of development will be discussed.
Country profiles (see Figure 1 for a summary of data for each of the three countries cited below.)
Tajikistan
In Tajikistan with a population of 6.9 million it is estimated that 41% of the inhabitants are living below the national poverty line. The health status is poor with an under-five mortality rate of 96 per 1000 and a life expectancy of 59 for men and 63 for women (World Bank, 2005). Major health problems in Tajikistan include the infectious diseases associated with developing countries, with malaria and TB presenting major problems. Alongside these chronic diseases such as heart disease, diabetes and cancer are also reported. During the late 1990s health expenditure fell to less than 2% of GDP, but it has been increasing gradually in recent years. Current health expenditure, at 54 international dollars per capita (compare to Turkey, 557; Uzbekistan, 160) is still the lowest in the WHO Europe area, both absolutely and as a proportion of GDP (4.4%) (WHO, 2007). Of this expenditure only 21% is Government expenditure, the remainder being paid for privately by individuals (WHO, 2007). Government expenditure was traditionally focused on hospitals, to the neglect of Primary Health Care, with hospitals allocated 78% of the budget in 1998 (WHO, 2000). In March 2002, the Government of Tajikistan approved a health reform programme, to reallocate resources from hospitals to Primary Health Care. Nonetheless, low levels of resourcing of health services continue to present major challenges to the health of Tajikistan's population. Tajikistan's reform programme aims to deliver Family Medicine through teams of Family Physicians and Family Health Nurses (MOH, Tajikistan, 2002). Workforce changes are required, including greater numbers of generalist physicians, and a greater proportion of nurses taking on clinical responsibilities. In 1998 the number of physicians recorded was 11,771 while the number of nurses was 34,452, a ratio of 1:3.4. Tajikistan's Ministry of Health now aims to reduce the numbers of physicians, and increase the numbers of nurses, to arrive at a ratio of 1:6 (WHO, 2000). In order to enable nurses to take on greater clinical responsibilities, their level of education and skills are also being increased (Parfitt, Mughal, & Thomas, 2008).
Uzbekistan
Uzbekistan has a population that has doubled since the 1970s to an estimated 26.9 million. Currently the growth rates have radically reduced and population growth in 2005 was estimated at 1.5%. Estimates of life expectancy and infant mortality are variable but according to WHO Regional Office statistics they are reported as 70.5 life expectancy and infant mortality at 68 per 1000. The most common causes of death in Uzbekistan are diseases of the circulatory system; malignant diseases are the second most prevalent cause of death. Tuberculosis is the main cause of death from infectious diseases and affects males almost two and half times more than females. Maternal mortality was recorded at 24.24 per 100,000 live births which is five times higher that the EU15 average of 5.64 per 100,000 live births. HIV is a newly emerging challenge with injecting drug use being the main cause of transmission (Ahmedov, Azimov, Alimova, & Bernd, 2007). Health expenditure as a percentage of GDP is 2.4 and has been decreasing since 1994 when it was 4.6. Current health expenditure is estimated at 169 international dollars per capita (compare to Turkey, 557; Tajikistan 54) WHO estimates that that public health expenditure amounted to only 42.1% of the total health expenditure in 2004. These figures do not take into account the out of pocket informal payments that supplement government payment system.
Uzbekistan began its major reforms in the health sector in the second half of the 1990s and in 1996 a new legal framework for the health sector was developed and passed by the Parliament. This new law identified a new vision for the Uzbek health system with principles that included human rights recognition, accessibility of health services for the whole population, prevention of disease and ill health, social protection for those who become ill and an effort to increase research and development and lessen the gap between science and medicine. Definitions of the different types of care that could be provided were also agreed. In 1998 a further document that decreed the key priority areas for development in the health service was issued. This document including a range of initiatives with a plan to strengthen primary health care services through the development of a network of PHC facilities. The education and retraining of nurses and doctors was also an important part of this plan. Training centres for the retraining of specialist doctors as General Practitioners were established within medical schools and at Family Physician training centres through out the country. A programme to develop the expertise of nurses and retrain them as family or generalist community nurses was also put in place. There is a specific focus for the nurses on maternal and child health care supported by the Asian Development Bank and it is expected that over 10,000 nurses will be retrained through this programme over a 5-year period (Ahmedov et al., 2007).
Azerbaijan
Azerbaijan has a population of 8.2 million with about 12% of this population being refugees primarily as a result of the Nagorno-Karabakh conflict. The country has suffered severe economic hardship with life expectancy reported currently as about 72 years. The main causes of death are the circulatory diseases and cancer. Infectious diseases and injuries also are leading causes. Infant mortality is reported at 12.8 per 1000 but it is estimated to be much higher than this round about 78 per 1000. Financing of the health service still remains the responsibility of the government with 78% from local budgets and 22% from central Republican funding. Funding levels for the health services are so low that informal payments of an estimated 49% make up the remaining health expenditure. An estimated 4.3% of the GDP was allocated to health in 1991 and this had fallen by 1.6% in 1999 while the current figure (2004) is estimated at 3.7%.
Primary Health Care in Azerbaijan still reflects the Soviet system with the provision of services at a range of levels from Feldsher aid posts, rural district hospitals and polyclinics. There is little tradition of Family Medicine and the key problem that arises is not the lack of staff but rather the poor capability and expertise and knowledge of the staff that are in position. A number of projects are being piloted across the country which aim to introduce a more family focused model of primary health care, and training programmes for staff are being put into place to assist in the delivery of these projects. Azerbaijan, in line with many previous Soviet Union countries, had a high proportion of medical staff (physicians) to population, higher than the European average. Currently it is estimated at 3.6/1000. The number of nurses is also high with one nurse to every 135 members of the population, 7.38/1000 population. The total number of nurses and ancillary workers is estimated at 59,100 (Holley, Akhundov, & Nolte, 2004) (Fig. 1).
Figure 1.
Data summary for Tajikistan, Uzbekistan and Azerbaijan.
Health system reform and human resource issues
Two key areas within the reform processes described above have a direct impact upon human resource provision in CIS countries. The shift from acute to primary health services and the financial models adopted by countries to support this shift and the development of the capability of the health service staff through education and training to equip them to deliver the primary health care service.
Acute to primary health care
Health system reform in the three countries highlighted above has brought about a number of changes in the public services for health care. A major shift has been made towards a more integrated approach to health care delivery within a Family Medicine Model where the Family Physician is the team leader. This model has led to a direct impact upon the roles and responsibilities of all staff within the PHC services. In the previous system role differentiation was specialised and very clear and staff understood the boundaries of their responsibilities. The new model requires a generalist approach with a holistic understanding of the community and individual patients. For nurses this means extended roles and for both nurses and doctors a different way of working, both with each other and with the community. The community becomes a partner in the care rather than simply having care given to them dictated by the health professionals. This is a completely new way of working for those who previously worked in the Soviet system of health care delivery and the motivation to change requires robust training and re-education programmes. It also requires improved pay and conditions and career opportunities that reflect performance and output rather than success in examinations, which has been the traditional way of accessing promotion opportunities. Funding for primary care services has been poor and countries are seeking different methods to raise the funds to support the service and in some cases there is still little evidence that sufficient funds are being passed onto the primary health care services in order for them to deliver the targets outlined in the health reform programmes. In Azerbaijan for example, it is estimated that it would cost US$ 15–20 per capita to provide the necessary package of PHC services but in 1999 13 districts in the country only received US$ 2–3 to cover all health services. In Uzbekistan acute care accounts for approximately 66% of the overall budget while rural primary health care units are estimated at receiving 7.8% in 2005. This again highlights the fact that the primary expenditure is still targeted towards acute services and not primary health care. There is also evidence from Uzbekistan that little of the health budget is spent on education and research (Holley et al., 2004).
The re-organisation of the health services has not as yet led to a direct or managed loss of jobs although natural wastage is high due to poor salaries and conditions of service. There is anecdotal evidence that things have improved marginally for the better but on the whole health care staff, especially those in the rural areas, receive low wages and poor recognition for their services.
The upgrading and refurbishing of the primary health and rural health centres, largely funded by World Bank and Asian Development Bank, has played an important part in the improvement of working conditions for staff and has had a positive affect on their morale and wellbeing. These improvements also influence the level of trust by the public towards health care workers and the health services in general. When health staff do not have the resources to provide the necessary care there is a consequent low uptake in both preventative and curative services as well as a by-passing of the system to alternative providers. The morale of health workers is damaged and along with it their ability to maintain competence to practise. Health workers, particularly in the public health sector, become marginalised and excluded from making their contribution to the health of the community.
In summary the health reforms proposed by many of the CIS countries are radical and directed towards the introduction of a family focused care model using the Family Physicians as the team leader supported by Family Health Nurses and other ancillary staff working together in an integrated team. The introduction of this service is still in the early phases and needs proper investment in order that staff receive appropriate education, remuneration and conditions of service to fulfil the aims of the reform process.
Education and training
The second major human resource issue associated with the health reform process is the capability of the staff and the development of competence to deliver the service.
Approaches to the training of staff to undertake their new roles is varied across the CIS countries but in principle there is a move towards Family Physician training at the postgraduate level for medical staff, and programmes of both pre- and post-qualifying education for nurses that meet the European standards for nurse education. In Tajikistan a pre-qualifying integrated programme for Family Health Nurses and General Nurses was introduced in 2002. This programme provides a 3-year generalist training course followed by a further year specialist training in Family Health Nursing. Nurses are equipped to work in any setting but the emphasis is on community and family based care. A post-qualifying 6-month programme to train Family Health Nurses is also available. Similar programmes have been developed in Kirghizstan, Kazakhstan and Uzbekistan. The major challenge in all of these countries is the lack of higher qualified nurses who are eligible to teach. Traditionally only doctors have been sufficiently qualified to teach nurses and although master's programmes for nurses have now been developed in Kirgizstan and Uzbekistan, in Azerbaijan and Tajikistan a Masters in Nursing is not yet available (Parfitt & Cornish, 2007). In Uzbekistan the B.Sc. and the Masters programme have been developed in the medical faculty alongside the development of a major ‘Train the Trainer’ programme for upgrading the skills of community based nurses. While the pre-qualifying training in Tajikistan is now three years, in Uzbekistan it remains at 2 years and still contains large amounts of general curriculum content. Azerbaijan is currently introducing Family Health Nurses in a designated World Bank pilot area and selected nurses are being sent outside the country to pursue higher degrees in nursing. This latter approach is not usually encouraged as it often results in the selected nurses remaining in the country where they were sent for further training rather than returning to contribute to the health services in their own country.
Following their training programme staff are required to move out of their comfort zone and position themselves in a place where they may lack confidence and the necessary skills to fulfil their role. A key issue that is faced by these newly trained staff is the lack of support and few role models with little guidance in meeting the primary health care demands placed upon them. Nurses in particular are often placed in difficult positions, for example in Tajikistan nurses who have undergone the Family Health Nurse retraining programme and have then been placed in a health centre with a physician who has not undergone the Family Physician training, and has little idea of the new approach and philosophy towards Primary Health Care, are left in a position where they cannot fulfil their new role and consequently revert to the old pattern of working (Parfitt & Cornish, 2007).
In summary, in order for both physicians and nurses to adapt to the very different approach required within a holistic family focused primary health care model, they need retraining both in terms of their skills and expertise, their ability to work as an integrated team and their understanding of how to engage the community in their own health improvement. To achieve this, programmes of education and retraining are required and new skills need to be learned. CIS countries have begun to put in place the necessary training programmes for both doctors and nurses, but it will take time to re-orientate the health professions in these countries towards a very different way of working.
Conclusion
The main human resource issue highlighted by the World Health Report is the lack of human resource capacity and the need for an increase in the numbers of skilled health care workers. In the CIS countries the issue is not the numbers of health staff but the skills and expertise of the staff available and the model of care within which they operate. Glatleider (2006) showed that the Soviet Union reports some of the highest levels of maternal and infant mortality in the European region, yet deliveries occur in institutions with 96–100% skilled birth attendants. This illustrates how the level of competence and the degree of expertise that the health professional has is as important if not more important than just large numbers of health workers. There is a danger in responding to the African lack of health workers by producing large numbers of health workers with limited skills. Having large numbers of health care workers will on its own not necessarily make the expected impact on improving the health of the communities they serve. It is also necessary to invest in the up-skilling of doctors, nurses, midwives and other mid-level health workers to work effectively and competently within well-supported primary health care systems with adequate pay and conditions.
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PII: S1322-7696(09)00003-1
doi:10.1016/j.colegn.2009.01.002
© 2009 Royal College of Nursing, Australia. Published by Elsevier Inc. All rights reserved.
